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Objective To evaluate long-term results and quality of life of patients undergoing laparoscopic antireflux surgery. Design A validated survey instrument, the Gastroesophageal Reflux Disease–Health-Related Quality-of-Life Scale (GERD-HRQL) was mailed to all patients who underwent laparoscopic fundoplications (LFs) from 1997 to 2006. Additional information was obtained regarding reintervention, satisfaction, and medication use. Setting Tertiary care referral center. Patients Four hundred five consecutive patients who underwent primary or redo LF from 1997 to 2006. Main Outcome Measures GERD-HRQL score, reoperation rate, and antireflux medication use. Results A 54% response rate was obtained. Median follow-up was 60 months (range, 4-75 months). In patients who underwent primary LF, the mean (SD) GERD-HRQL score was 5.71 (7.99) (range, 0-45, with 0 representing no symptoms). Seventy-one percent of patients were satisfied with long-term results. Forty-three percent of patients took antireflux medications at some point following surgery; half of these patients had no diagnostic testing to document GERD recurrence. Only 3 patients (1.2%) required reoperation. Patients undergoing redo LF had higher GERD-HRQL scores (mean [SD], 14.25 [10.33]), lower satisfaction (35%), and greater probability of requiring antireflux medication (78%). Patients with body mass indexes (BMIs) (calculated as weight in kilograms divided by height in meters squared) between 25 and 35 had lower GERD-HRQL scores than thin (BMI Conclusions Contrary to the medical literature, our results demonstrate that patients undergoing primary LF by an experienced surgical team have near-normal GERD-HRQL scores at long-term follow-up and low reoperation rates and are satisfied with their decision to undergo surgery. Results following redo LF are not as good, highlighting the importance of proper patient selection and surgical technique when performing primary LF.

Hypothesis: Widespread use of computed tomography and ultrasound has led to the identification of increasing numbers of patients with asymptomatic cystic lesions of the pancreas. Design: Retrospective case series of patients with pancreatic cystic lesions. Setting: University-affiliated tertiary care referral center. Patients: Two hundred twelve patients with pancreatic cystic lesions seen in our surgical practice during 5 years (April 1997-March 2002). Main Outcome Measures: Presence or absence of symptoms, cyst size and location, cytologic or pathologic diagnosis, surgical treatment, and outcome. Results: Seventy-eight (36.7%) of 212 patients were asymptomatic. Incidental cysts were smaller (3.3 3 ±1.9 vs 4.6 ±2.7 cm; P

ContextThe decentralization of clinical teaching networks over the past decade calls for a systematic way to record the case-mix of patients, the severity of diseases, and the diagnostic procedures that medical students encounter in clinical clerkships.ObjectiveTo demonstrate a system that documents medical students' clinical experiences across clerkships.Design and SettingsEvaluation of a method for recording student-patient clinical encounters using a pocket-sized computer-read patient encounter card at a US university hospital and its 16 teaching affiliates during academic years 1997-1998 through 1999-2000.ParticipantsA total of 647 third-year medical students who completed patient encounter cards in 3 clerkships: family medicine, pediatrics, and internal medicine.Main Outcome MeasuresNumber of patient encounters, principal and secondary diagnoses, severity of diseases, and diagnostic procedures as recorded on patient encounter cards; concordance of patient encounter card data with medical records.ResultsStudents completed 86 011 patient encounter cards: 48 367 cards by 582 students in family medicine, 22 604 cards by 469 students in pediatrics, and 15 040 cards by 531 students in internal medicine. Significant differences were found in students' case-mix of patients, the level of disease severity, and the number of diagnostic procedures performed across the 3 clerkships. Stability of the findings within each clerkship across 3 academic years and the 77% concordance of students' reports of principal diagnosis with faculty's confirmation of diagnosis support the reliability and validity of the findings.ConclusionsAn instrument that facilitates students' documentation of clinical experiences can provide data on important differences among students' clerkship experiences. Data from this instrument can be used to assess the nature of students' clinical education.

Hypothesis Staging laparoscopy in patients with pancreatic cancer identifies unsuspected metastases, allows treatment selection, and helps predict survival. Design Inception cohort. Setting Tertiary referral center. Patients A total of 125 consecutive patients with radiographic stage II to III pancreatic ductal adenocarcinoma who underwent staging laparoscopy with peritoneal cytologic examination between July 1994 and November 1998. Seventy-eight proximal tumors and 47 distal tumors were localized. Interventions Based on the findings of spiral computed tomography (CT) and laparoscopy, patients were stratified into 3 groups. Group 1 patients had unsuspected metastases found at laparoscopy and were palliated without further operation. Group 2 patients had no demonstrable metastases, but CT indicated unresectability due to vessel invasion. This group underwent external beam radiation with fluorouracil chemotherapy followed in selected cases by intraoperative radiation. Patients in group 3 had no metastases or definitive vessel invasion and were resection candidates. Main Outcome Measure Survival. Results Staging laparoscopy revealed unsuspected metastases in 39 patients (31.2%), with 9 having positive cytologic test results as the only evidence of metastatic disease (group 1). Fifty-five patients (44.0%) had localized but unresectable carcinoma (group 2), of whom 2 (3.6%) did not tolerate treatment, 20 (36.4%) developed metastatic disease during treatment, and 21 (38.2%) received intraoperative radiation. Of 31 patients with potentially resectable tumors (group 3), resection for cure was performed in 23 (resectability rate, 74.2%). Median survival was 7.5 months for patients with metastatic disease, 10.5 months for those receiving chemoradiation, and 14.5 months for those who underwent tumor resection ( P =.01 for group 2 vs group 1; P Conclusions Staging laparoscopy, combined with spiral CT, allowed stratification of patients into 3 treatment groups that correlated with treatment opportunity and subsequent survival. Among the 125 patients, laparoscopy obviated 39 unnecessary operations and irradiation in patients with metastatic disease not detectable by CT. Laparoscopic staging can help focus aggressive treatment on patients with pancreatic cancer who might benefit.

Objective To assess the implications of positive cytology for malignant cells (positive results) from peritoneal washings in the management of patients with pancreatic cancer. Design Retrospective cohort study. Setting Referral practice in a university hospital. Patients A total of 32 consecutive pancreatic cancer patients with positive results from peritoneal washings during a 4-year period, 17 with visible biopsy-proven intra-abdominal metastases at the time of laparoscopy or laparotomy and 15 without visible metastases. A treatment-matched control group of 30 patients was randomly selected from a group of 105 patients with negative cytology for malignant cells (negative results) from peritoneal-fluid cytology. Interventions Eight of 17 patients with visible metastases underwent treatment with chemotherapy, radiation, or both; 13 of the 15 patients with no visible metastases underwent further treatment, including pancreatic resection in 2 patients and external beam radiation in 13 patients (3 with intraoperative radiation therapy). Main Outcome Measures Time to metastases and mortality. Results Median survival among patients with and without visible metastasis was 7.8 months and 8.6 months, respectively ( P =.95), despite the fact that patients without visible metastases received more treatment. Patients without visible metastases at presentation were found to have metastatic disease as documented by computed tomographic scan or subsequent laparotomy at a median time of 2.9 months. The survival of treatment-matched patients with negative cytology was significantly longer (median, 13.5 months; P= .04). Conclusions Pancreatic cancer patients with peritoneal micrometastases have a dismal outcome even without macroscopic metastases. Since these patients do not benefit from local therapy, the finding of a positive result from peritoneal-fluid cytologic testing contraindicates further irradiation or surgery, except for specific complications.

Background The pancreas is an unusual but occasionally favored site for metastases, notably from carcinomas of the kidney and lung. The pancreas may be the only identified locus of spread, and therefore may provide an opportunity for significant palliation or even cure using pancreatectomy. Objective To report the treatment and outcome of patients presenting with metastases to the pancreas. Design Five-year survey. Setting Tertiary referral center. Patients Ten patients with apparently isolated metastases to the pancreas were identified from January 1, 1991, to December 31, 1995. All patients were followed up until death or to September 1997. Results The patients had been treated previously for carcinoma of the lung (n=4), renal cell carcinoma (n=2), sarcoma (n=2), breast carcinoma (n=1), and endometrial carcinoma (n=1). The interval between primary treatment and presentation of the metastases averaged 70 months (14-24 months for lung cancer, 10 and 22 years for renal cell carcinoma, 4 and 6 years for sarcoma, 8 years for breast cancer, and 36 months for endometrial carcinoma). Metastases were initially misdiagnosed as primary pancreatic cancers in 7 patients. In 4 patients (those with renal cell cancer and sarcomas), the tumor was completely resected using total pancreatectomy (n=3) or Whipple resection (n=1). Survival after diagnosis averaged 22 months. Two of the 4 patients undergoing pancreatic resection remain alive and well 20 and 25 months after pancreatectomy. Conclusions The pancreas may be the presenting and perhaps sole locus for metastasis, typically years after treatment for certain extrapancreatic malignant neoplasms. Recognition and surgical treatment can provide worthwhile palliation and long-term survival.

Objective: To delineate factors determined preoperatively, which predict successful local resection of ampullary neoplasms. Design: Retrospective review of case series of the authors' experience from 1988 through 1995. The median follow-up of patients with malignancies was 29 months. Setting: Tertiary care university teaching hospital. Patients: Twenty-seven patients underwent surgery. The decision to perform either an ampullectomy or pancreaticoduodenectomy (PD) was based on the size of the lesion, the presence of a "field defect" (ie, familial polyposis), depth of invasion determined by preoperative endoscopic ultrasound, and extent of pancreatic and bile duct involvement seen on endoscopic retrograde cholangiopancreatography. Interventions: Fourteen patients underwent ampullectomy, 12 patients underwent PD, and one patient had a retroperitoneal node biopsy performed without resection of the primary tumor. Main Outcome Measures: Resectability, morbidity, and mortality. Results: Depth of invasion was accurately determined in nine of 12 patients studied by preoperative endoscopic ultrasound. Preoperative endoscopic biopsy specimens were obtained in 21 patients and were inaccurate in seven of 21 cases. The length of stay following local resection was 10.5±3.7 days vs 15.4±5.8 days following PD (P=.02). One patient died following PD, and there were no deaths following ampullectomy. Six of 12 patients undergoing PD had postoperative complications vs two of 14 patients undergoing local resection. Conclusions: Ampullectomy is the procedure of choice for resecting benign lesions smaller than 3 cm, small neuroendocrine tumors, and T1 carcinomas of the ampulla. While endoscopic ultrasonography is helpful in identifying stage Tl lesions suitable for local resection, no preoperative test proved accurate enough to substitute for clinical judgment and intraoperative pathological confirmation. (Arch Surg. 1996;131:366-371)

Background: Alcohol predisposes to acute pancreatitis by an unknown mechanism and is known to reduce regional pancreatic blood flow. Objective: To investigate whether increased blood alcohol causes functional impairment of pancreatic microperfusion as indicated by reduced tissue oxygenation. Design: Prospective, randomized, controlled study. Setting: University hospital laboratory. Subjects: Forty adult female Wistar rats. Interventions: Intravenous infusion of ethanol (2 g/kg) or saline over 60 minutes. Tissue hemoglobin oxygenation saturation and hemoglobin content were measured using reflectance spectroscopy in the pancreas, stomach, and kidney at baseline and at 10-minute intervals for 1 hour. Results: Blood ethanol levels (mean±SEM) peaked at 1810±94 mg/L. Compared with saline controls, pancreatic hemoglobin oxygen saturation in ethanol-treated rats had significantly decreased by 40 minutes and remained depressed, while pancreatic hemoglobin content was unchanged. The magnitude of the depression was at least as great as that previously observed in acute experimental pancreatitis of moderate severity. Neither hemoglobin oxygen saturation nor hemoglobin content was affected in the stomach or kidney by ethanol. Conclusion: A raised blood ethanol level was associated with acutely decreased hemoglobin oxygen saturation in the pancreas but not in the stomach or kidney. This observation of provoked hypoxia provides a possible mechanism by which alcohol contributes to pancreatic injury. (Arch Surg. 1995;130:357-361)

Objective: To compare laparoscopic (LNF) with open Nissen fundoplication (ONF) in terms of hospital charges, efficacy, and patient satisfaction. Design: A prospective, nonrandomized study with a median follow-up of 370 days. Setting: Two tertiary care university hospitals. Patients: Eighty-six patients with complications of gastroesophageal reflux who had not had previous antireflux surgery were studied. Patients chose ONF or LNF following discussion with the surgeon; 12 underwent ONF and 74 underwent LNF, of whom eight required conversion to laparotomy. Main Outcome Measures: Hospital charges, disability, satisfaction, and side effects of fundoplication. Results: Patients were demographically similar. Total charges (mean±SD) for LNF ($11 673±$4723) were significantly less than for ONF ($18 394±$17 264). Patients who underwent LNF returned to work sooner (10±3 days) than those who underwent ONF (28±1 days). Bloating, dysphagia, and recurrent heartburn occurred with equal frequency in both groups. Recurrent reflux occurred in four of 74 LNF patients and one of 12 ONF patients. Overall satisfaction scores were similar, irrespective of operative technique (LNF, 3.35±0.87; ONF, 3.50±0.94. Conclusions: Laparoscopic Nissen fundoplication is as effective as ONF in the treatment of complications of gastroesophageal reflux disease and appears to cost less and lead to faster recovery from surgery, but does not result in higher patient satisfaction than ONF. The most important factor in patient satisfaction is the abolition of preoperative symptoms rather than the type of operation. (Arch Surg. 1995;130:289-294)

Contrast-enhanced computed tomography is widely used to evaluate severe acute necrotizing pancreatitis (ANP) by demonstrating areas of malperfusion, which might indicate irreversible necrosis. Because of our prior finding that the intravenous contrast medium (CM) accentuates the severity of ANP by promoting further necrosis and higher mortality, we sought to investigate the mechanism by which this injury is mediated.Mild acute pancreatitis was induced in Sprague-Dawley rats with intravenous caerulein hyperstimulation; and severe ANP, with intravenous caerulein plus intraductal glycodeoxycholic acid. Control animals and rats with pancreatitis were randomized to be given intravenous CM or saline.Diffuse reflectance spectroscopy was used to measure the index of hemoglobin content and oxygen saturation in pancreatic tissues in vivo.Oxygen saturation of hemoglobin was increased in animals with mild acute pancreatitis (AP) (mean [+/- SEM], 58.7% +/- 1.2% vs 55.2% +/- 1.5% in control animals; P.05) and was decreased in animals with ANP (51.2% +/- 1.2% vs 55.2% +/- 1.5%; P.05). Fifteen minutes after the infusion of CM, oxygen saturation of hemoglobin significantly decreased further in animals with ANP (51.4% +/- 1.8% before infusion of CM vs 46.1% +/- 1.7% at 15 minutes; P.05) and remained significantly below the comparable group receiving intravenous saline for the entire 60-minute test. This decrement was not observed in animals with ANP given saline or in animals with mild AP or in control animals after infusion of saline or CM. The index of hemoglobin content remained unchanged throughout the experiment in all groups.The prolonged reduction of oxygen saturation of hemoglobin in the pancreas following the administration of intravenous CM in rats with severe ANP indicates that CM impairs the pancreatic microcirculation in necrotizing forms of AP. This may explain our previous finding that CM increases pancreatic injury and mortality in rodents with ANP, and it underlines our concern that the use of contrast-enhanced computed tomography early in human AP may promote the evolution of pancreatic necrosis.

• We describe seven cases of thrombosis of the portal and splenic vein after elective splenectomy. The diagnosis was initially unrecognized in all patients and was confused with biliary sepsis (three cases), postoperative pancreatitis (three cases), or pulmonary emboli (one case). Two patients in whom the diagnosis of portal vein thrombosis was not made within 3 days of disease onset died. In the five survivors, the diagnosis was based on clinical suspicion, confirmed with color flow Doppler ultrasonography or computed tomography with intravenous contrast material, and treated with thrombolytic agents, anticoagulants, and antibiotics. In two patients, splenic vein thrombus was visualized on initial postoperative imaging studies and the thrombus subsequently extended into the portal vein. Portal vein thrombosis should be considered in patients with fever and abdominal complaints after splenectomy. Urgent treatment with thrombolysis and anticoagulants may preserve bowel integrity and be lifesaving. ( Arch Surg . 1993;128:565-570)